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PEDIATRICS Vol. 104 No. 6 December 1999, pp. 1404-1406
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ABSTRACT |
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Top
Abstract
Background
Conclusion
Recommendation
References
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Since 1997, when the American Academy of Pediatrics (AAP) initially recommended expanded use of inactivated poliovirus vaccine (IPV) for routine childhood immunization against poliovirus infection, the occurrence of vaccine-associated paralytic poliomyelitis (VAPP) has decreased in the United States. However, VAPP will not be eliminated until oral poliovirus vaccine (OPV) no longer is given. As a result of continuing progress toward global eradication of poliomyelitis, the risk of imported infection has continued to decrease. Concomitantly, the use of IPV has increased substantially with the corresponding decrease in the use of OPV, indicating widespread acceptance by health care professionals and parents of the sequential or all-IPV immunization schedule previously recommended by the AAP. In addition, availability of OPV will be substantially diminished beginning in early 2000. To eliminate VAPP in the context of decreasing risk of wild-type poliovirus importation, the AAP recommends an all-IPV schedule for routine childhood immunization beginning in early 2000. The AAP further recommends that, effective immediately, OPV no longer should be purchased for routine use. Guidelines are given for utilization of remaining supplies of OPV during the transition in early 2000 to the all-IPV schedule.
Since 1996, recommendations for routine immunizations of
infants and children in the United States against poliomyelitis have evolved from use of oral poliovirus vaccine (OPV) exclusively to
increasing use of inactivated poliovirus vaccine (IPV). In 1997, the
American Academy of Pediatrics (AAP) issued guidelines for expanded use
of IPV1 and the Advisory Committee on Immunization
Practices (ACIP) of the Centers for Disease Control and Prevention
(CDC) recommended the sequential IPV-OPV schedule.2 These
changes in immunization policy resulted from the occurrence of 8 to 9 cases yearly of vaccine-associated poliomyelitis (VAPP), no
reported indigenously acquired cases of poliomyelitis caused by
wild-type poliovirus in the United States since 1979, and the continuing progress of the global eradication program sponsored by the
World Health Organization (WHO), targeted for completion by the end of
2000.
In late 1998 and 1999, 2 further changes in the recommendations
for immunization against poliovirus infection occurred. First, the AAP
recommended in January 1999 that the first 2 doses of polio vaccine for
routine immunization should be IPV in most circumstances.3 The AAP further noted that an IPV-only schedule for all doses was
acceptable and the only means to eliminate VAPP, and that the IPV-only
regimen likely would be recommended for all children in the near
future, assuming continued progress in global eradication. Second, the
ACIP in June 1999 recommended the IPV-only regimen for routine
childhood immunization beginning January 1, 2000.4 Both of
these changes in policy were based on the continuing, albeit rare,
occurrence of VAPP, the similar immunogenicity of IPV to that of OPV
for primary immunization, the continued progress in global eradication
of wild-type poliovirus, and the acceptance of IPV for primary
immunization by health care professionals and parents.
Surveillance by the CDC of the purchase of doses of OPV and IPV in the
United States demonstrated that whereas 6% of all poliovirus vaccine
doses distributed in 1996 were IPV, 29% and 34%, respectively, in
1997 and 1998, were IPV doses (W. Orenstein, CDC, written
communication, August 1999). Through August 31, 1999, 69% of doses
purchased in 1999 were IPV, indicating further increase in the
acceptance of IPV and decreasing utilization of OPV. In a recent AAP
study assessing practices for polio immunization, 70% of pediatricians surveyed in mid-1998 reported that they usually recommend the sequential schedule.5 The increased utilization of IPV in
the past several years and the resulting additional injections have not
been associated with decreased coverage with polio vaccine or with
other childhood vaccines.6,7
The use of IPV is likely to increase dramatically in the near future
because of the limited availability of OPV. The CDC contract for OPV,
which supplies vaccines for the Vaccines for Children (VFC) program, is
scheduled to expire in December 1999. As a result of the recent ACIP
recommendation, this contract will not be renewed. The VFC program
provides approximately 35% of childhood vaccines for infants and
children in the United States (D. Mason, written communication, August
1999). In a 1997 assessment, 74% of all children received all or some
of their immunizations from a VFC-enrolled provider.8
Whether OPV will continue to be commercially available from the only US
manufacturer after 1999 is uncertain.
The increasing use of IPV has led to a decrease in the reported number
of cases of VAPP. Whereas an average of 8 cases were reported annually
between 1980 and 1994 in the United States, the CDC has confirmed 5 cases in 1997 and only 1 case in 1998.9 All cases occurred
in children or contacts of children immunized with only OPV; 4 were
recipients and 1 was a contact. Several additional cases associated
with OPV in 1998 are under investigation by the CDC (W. Orenstein CDC,
written communication, September 1999). This decrease indicates the
success of the sequential schedule in reducing VAPP. However, as long
as OPV is given for any doses of polio immunization, the potential for
VAPP in nonimmunized contacts and in the community will continue to
exist.
The adoption by the ACIP and endorsement by the AAP of the sequential
schedule in 1997 was based, in part, on the need to maintain optimal
intestinal immunity. The administration of 2 doses of OPV would prevent
community transmission in a case of inadvertent introduction of
wild-type poliovirus, ie, a population-based barrier for overall public
health benefit.1,2 However, the only identified imported
case of paralytic poliomyelitis since 1986 in the United States
occurred in 1993 in a 2-year-old child from Nigeria who had been
transported to the United States for treatment of
poliomyelitis.2 The risk of importation continues to
decrease as a result of the considerable progress toward global
eradication.10 Poliovirus transmission in 1998 was
confined largely to the remaining major foci in southern Asia, western
and central Africa, and the Horn of Africa. The southern Asia reservoir
countries reported 80% or more of all global cases of polio in 1998. A
plan for accelerating poliovirus eradication has been developed by the
WHO in collaboration with its partners to achieve the goal of global
eradication by the end of 2000.
The AAP, in its 2 recent policy statements on prevention of
poliomyelitis, indicated that the IPV-only regimen likely would be
recommended for all children in the near future.1,3 In
view of the continuing, albeit rare, occurrence of VAPP, the decreasing
risk of importation into this country, the acceptance of IPV by health
care professionals, and the probable lack of availability of OPV in the
near future, the AAP recommends an all-IPV schedule for routine
immunization of all children in the United States beginning in early
2000. While the ACIP has adopted the date of January 1, 2000,4 this date may not be feasible for physicians and
health care organizations with remaining supplies of OPV. To implement
the transition to an all-IPV schedule as rapidly as possible and to
eliminate the residual risks of OPV-associated VAPP, supplies of OPV no
longer should be purchased for the routine immunization of infants and
children. Because cases of VAPP have not occurred in association with
children immunized according to the sequential schedule, remaining
supplies of OPV can be used to complete the sequential schedule in
children who already have received at least 2 or more doses of IPV and
for 4- to 6-year-old children receiving their fourth dose of vaccine,
irrespective of the prior vaccines that were given. Priority in this
circumstance should be given to children at 4 to 6 years of age;
vaccination of these children should be associated with the least risk
of VAPP because they are continent of stool and are unlikely at this age to have an unidentified immunodeficiency. Use of IPV for the fourth
dose also is acceptable. OPV also may be given to children who
previously received 2 or 3 doses of this vaccine.
1. Effective in early 2000, IPV is routinely
recommended for all children at 2 months, 4 months, 6 to 18 months, and
4 to 6 years of age.
2. Transition to the all-IPV schedule should be completed as soon
as feasible and no later than the first 6 months of 2000. To effect
this change as soon as possible, OPV supplies no longer should be
purchased for routine use.
3. OPV should be used only in the following circumstances,
unless otherwise contraindicated:
a a. Mass vaccination
campaigns to control outbreaks of paralytic poliomyelitis.
b b. Unvaccinated children who will be traveling in less
than 4 weeks to areas where polio is endemic or epidemic, ie, those for
whom time before departure is insufficient for administration of 2 doses of IPV.
c c. Children of parents who do not
accept the recommended number of vaccine injections to fulfill the
current childhood immunization schedule may receive OPV for the third
or fourth dose. However, OPV should not be given for the first or
second dose of the schedule.
d d. During the
transition to an all-IPV schedule in early 2000, remaining supplies of
OPV should be preferentially used for 4- to 6-year-old children who
have previously received 3 doses of any poliovirus vaccine to fulfill
requirements for school entry. Administration of OPV to children who
have previously received 2 doses of IPV or OPV also is acceptable for
depletion of existing OPV supplies.
4. Whenever OPV is administered, the risk of VAPP in recipients
and contacts should be discussed with the parents or caregivers.
5. For children who have previously received only OPV and are
scheduled to receive their fourth dose for school entry, IPV may be
given to complete the routine schedule. Four doses of any combination
of IPV or OPV by age 4 to 6 years of age are considered immunologically
equivalent to a complete poliovirus immunization series of all-IPV,
all-OPV, or the sequential IPV-OPV schedule when administered according
to the recommendations for minimum ages and intervals.11
6. Precautions or contraindications in administration of IPV and
OPV remain unchanged from those in the current edition of the Red
Book.11,12
7. If an outbreak of wild-type poliovirus infection occurs in the
United States, OPV is the vaccine of choice to control most effectively
the spread of infection. The AAP supports the need for sufficient
federal resources to ensure an adequate supply of OPV for outbreak
control in such a public health emergency.
8. The AAP supports the WHO recommendation for use of OPV to
achieve global eradication of poliomyelitis, especially in geographic areas with continued or recent circulation of wild-type poliovirus.
COMMITTEE ON INFECTIOUS DISEASES, 1999-2000
EX-OFFICIO
LIAISONS
CONSULTANT
BACKGROUND
Top
Abstract
Background
Conclusion
Recommendation
References
CURRENT CONSIDERATIONS
CONCLUSION
Top
Abstract
Background
Conclusion
Recommendation
References
RECOMMENDATIONS
Top
Abstract
Background
Conclusion
Recommendation
References
Jon S. Abramson, MD, Chairperson
Carol J. Baker, MD
Margaret C. Fisher, MD
Michael A. Gerber, MD
H. Cody Meissner, MD
Dennis L. Murray, MD
Gary D. Overturf, MD
Charles G. Prober, MD
Margaret B. Rennels, MD
Thomas N. Saari, MD
Leonard B. Weiner, MD
Richard J. Whitley, MD
Georges Peter, MD
Larry K. Pickering, MD
Noni E. MacDonald, MD
Anthony Hirsch, MD
Pediatric Practice Action Group
Richard F. Jacobs, MD
American Thoracic Society
Gilles Delage, MD
Canadian Paediatric Society
Scott Dowell, MD, MPH
Centers for Disease Control and Prevention
Walter A. Orenstein, MD
Centers for Disease Control and Prevention
Peter A. Patriarca, MD
Food and Drug Administration
N. Regina Rabinovich, MD
National Institutes of Health
Martin G. Myers, MD
National Vaccine Program Office
Edgar O. Ledbetter, MD
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FOOTNOTES |
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The recommendations in this statement do not indicate an exclusive course of treatment or serve as a standard of medical care. Variations, taking into account individual circumstances, may be appropriate.
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ABBREVIATIONS |
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OPV, oral poliovirus vaccine; IPV, inactivated poliovirus vaccine; AAP, American Academy of Pediatrics; ACIP, Advisory Committee on Immunization Practices; CDC, Centers for Disease Control and Prevention; VAPP, vaccine-associated paralytic poliomyelitis; WHO, World Health Organization; VFC, Vaccines for Children program.
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REFERENCES |
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Top
Abstract
Background
Conclusion
Recommendation
References
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United States, 1997.
MMWR Morb Mortal Wkly Rep.
1998;
47:1017-1019 [Medline]United States, 1998.
MMWR Morb Mortal Wkly Rep.
1999;
48:829-830 [Medline]1997-1998.
MMWR Morb Mortal Wkly Rep.
1999;
48:416-421 [Medline]This article has been cited by other articles:
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  M. Dubik and L. Barton The Elimination of Vaccine-Associated Polio in the US AAP Grand Rounds, January 1, 2005; 13(1): 9 - 10. [Full Text] [PDF]
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 L. N. Alexander, J. F. Seward, T. A. Santibanez, M. A. Pallansch, O. M. Kew, D. R. Prevots, P. M. Strebel, J. Cono, M. Wharton, W. A. Orenstein, et al. Vaccine Policy Changes and Epidemiology of Poliomyelitis in the United States JAMA, October 13, 2004; 292(14): 1696 - 1701. [Abstract] [Full Text] [PDF]
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 S. Caddle and H. M. Adam Enteroviruses Pediatr. Rev., October 1, 2003; 24(10): 358 - 359. [Full Text] [PDF]
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 D. P. Greenberg and S. Feldman Vaccine Interchangeability Clinical Pediatrics, March 1, 2003; 42(2): 93 - 99. [Abstract] [PDF]
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 Immunocompromised Children Red Book, January 1, 2003; 2003(1): 69 - 81. [Full Text]
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 P. H. Dennehy Active Immunization in the United States: Developments over the Past Decade Clin. Microbiol. Rev., October 1, 2001; 14(4): 872 - 908. [Abstract] [Full Text] [PDF]
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A. Epee-Bounya, B. A. Gitterman, and R. Y. Moon Parental Opinions Regarding Poliomyelitis Immunizations Clinical Pediatrics, August 1, 2001; 40(8): 435 - 440. [Abstract] [PDF]
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 J. A. Taylor, P. M. Darden, D. A. Brooks, J. W. Hendricks, A. E. Baker, A. B. Bocian, K. Rohder, and R. C. Wasserman Impact of the Change to Inactivated Poliovirus Vaccine on the Immunization Status of Young Children in the United States: A Study From Pediatric Research in Office Settings and the National Medical Association Pediatrics, June 1, 2001; 107(6): e90 - 90. [Abstract] [Full Text] [PDF]
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Committee on Infectious Diseases Recommended Childhood Immunization Schedule---United States, January-December 2000 Pediatrics, January 1, 2000; 105(1): 148 - 151. [Full Text] [PDF]
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